Background

 

 

Epidemiology                                                                                                                    

 

Third most common fracture after hip and distal radius

70% in patients aged 60 years or older

 

Etiology

 

Elderly patients - osteoporosis

Young patients - high energy trauma

 

Anatomy

 

Surgical neck - junction of diaphysis and metaphysis

Anatomical neck - junction of head and metaphysis

Neck shaft angle 130^o

Head retroverted 20^o relative to shaft

 

Blood supply 

 

 

Anterior humeral circumflex	Posterior Humeral circumflex	Rotator cuff
Major supply Anterolateral branch - runs in intertubercular groove lateral to biceps - becomes arcuate artery - supplies GT / LT / head	Small contribution posterior head Allows head to survive with both tuberosities fractured	Supplies blood to tuberosities in fractures
Nearly always disrupted in fractures

 

Neer Classification

 

Displaced fragments - > 1 cm displaced and/or > 45^o angulated

 

Number of parts - 2, 3 or 4

 

Two part	Three part	Four part
Surgical neck fracture Anatomical neck fracture Greater tuberosity fracture Lesser tuberosity fracture	Surgical neck + greater tuberosity Surgical neck + lesser tuberosity	Surgical neck + greater tuberosity + lesser tuberosity
Fracture dislocations	Fracture dislocations Head split	Fracture dislocations

 

Two part

 

Displaced greater tuberosity fracture

 

Displaced lesser tuberosity fracture

 

Two part proximal humerus fracture

 

Two part proximal humerus fracture dislocation posterior

 

Three part

 

Three part with greater tuberosity fracture

 

Three part fracture dislocation anterior

 

Three part fracture dislocation with anatomical neck

 

Three part head splitting fracture

 

Four part

 

 

Avascular necrosis (AVN)

 

 

In most fractures, arcuate artery is disrupted, but head survives

- posterior circumflex artery is sufficient

- risk increases with amount of displacement

- 4 part fracture 30%

- 3 part fracture 15%

 

Hertel et al J Should Elbow Surg 2004

- two criteria to predict ischaemia / 97% predictive if both factors present

- metaphyseal head extension < 8 mm

- medial hinge displaced > 2mm

 

Deforming Forces

 

2 part fracture	Greater tuberosity fracture	Lesser tuberosity fracture
Pectoralis major displaces shaft medially Head internally rotated by SSC	Fragment pulled postero-superior Combination of SS / IS / T minor	Displaced medially by subscapularis

 

Management

 

Options

 

Nonoperative

Operative - ORIF (plate, IMN), hemiarthroplasty, reverse TSA

 

Operative versus non operative

 

Nonoperative versus ORIF / Hemiarthroplasty

 

Rangan et al JAMA 2015

- PROFHER trial

- 250 patients RCT of nonoperative versus ORIF/hemiarthroplasty

- mean age 66 (range, 24 - 92)

- 215 patients

- no difference in functional outcomes

 

Launonen et al PLoS Med 2023

- RCT of 160 patients nonoperative v ORIF v hemiarthroplasty

- > 60 years and displaced 3 or 4 part SNOH

- non difference in functional outcomes

- complications: nonoperative 6%, ORIF 45%, hemiarthroplasty 10%

 

Nonoperative versus Reverse TSA

 

Miquel et al JSES 2024

- RCT of 81 patients rTSA v nonoperative

- > 70 years and displaced 3 or 4 part SNOH

- 8 point better Constant score with rTSA

 

Nonoperative versus ORIF

 

Launonen et al PLoS Med 2019

- RCT of 88 patients nonoperative versus ORIF

- > 60 years and displaced 2 part SNOH

- no difference in outcomes

 

Operative management

 

Intra-medullary nail versus ORIF with plate

 

Boyer et al Int Orthop 2021

- RCT of 85 patients ORIF v IMN

- mean age 74 years and displaced 3 or 4 part SNOH

- better outcome scores and lower complications with IMN

 

De Joseph et al Cureus 2024

- systematic review of ORIF v IMN

- IMN shorter OR times and blood loss

- similar functional outcomes and complication rates

 

Reverse TSA versus ORIF with plate

 

Fraser et al JBJS Am 2020

- DelPhi trial

- RCT of 124 patients rTSA v ORIF

- > 65 years and displaced 3 or 4 part SNOH

- 14 point better Constant score with rTSA

 

Reverse TSA versus hemiarthroplasty

 

Jonsson et al JSES 2021

- RCT of 99 patients rTSA v hemiarthroplasty

- > 70 years and displaced 3 or 4 part SNOH

- 10 point better Constant score with rTSA

- better ROM with rTSA: abduction 110 v 80, flexion 125 v 90

 

Nonoperative treatment

 

Rehabilitation

 

Challoumas et al BMC Musculoskeletal 2025

- 1 week sling v 3 - 4 week sling immobilization

- meta-analysis of 6 RCTs

- no difference in outcome

- better at 3 months with early ROM

 

Non-union

 

 

Options

- ORIF + fibular strut

- revTSA

 

Malunion

 

 

Lu et al JSES 2023

- systematic review of early versus delayed rTSA for SNOH

- better ROM and outcome scores with early rTSA

- increased complication rate with delayed rTSA